Provider Demographics
NPI:1396198198
Name:OPTIMA DENTAL
Entity Type:Organization
Organization Name:OPTIMA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIJI
Authorized Official - Middle Name:
Authorized Official - Last Name:SEETHARAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-666-7415
Mailing Address - Street 1:222 COMMERCE CIR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007-3113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 COMMERCE CIR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-3113
Practice Address - Country:US
Practice Address - Phone:732-666-7415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS039249OtherSTATE LICENSE